No. RM : ………………………………………….

PEMERINTAH KABUPATEN SRAGEN

RSUD dr. SOEHADI PRIJONEGORO SRAGEN Nama Pasien : ………………………………………….
Jln. Raya Sukowati No. 534 Telp. (0271) 891068 Sragen 57215 Tanggal Lahir : ………………………………………….
Website http://www.rsspsragen.com
E-mail : rsudsragen1958@gmail.com Jenis Kelamin : Laki-laki Perempuan
Alamat : ………………………………………….
ASESMEN MEDIS RAWAT INAP ………………………………………….
MATA
Diisi Oleh Dokter
Tanggal : Jam :
A. ANAMNESA
1. Keluhan utama
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2. Riwayat penyakit dahulu
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3. Riwayat penyakit sekarang
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4. Riwayat penyakit keluarga
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B. PEMERIKSAAN FISIK
1. Vital Sign
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2. Cranium
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3. Leher
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4. Thorax
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5. Abdomen
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6. Genitalia
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7. Extremitas
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RM : 1m/Rev.1/2019 Asesmen Medis Rawat Inap Mata Hal. 1

 STATUS LOKALIS

VISUS
KOREKSI
SKIASKOPI
BULBUS KOLORIS
PARESE, PARALYSE
SUPERCILIA
PALPEBRA SUPERIOR
PALPEBRA INFERIOR
CONJUNCTIVA PALPEBRALIS
CONJUNCTIVA FORNICES
CONJUNCTIVA BULBI
SCLERA
CORNEA
CAMERA OCULI ANTERIOR
IRIS
PUPIL
LENSA
FUNDUS REFLEKS
CORPUS VITREUM
TENSIO OCULI
SISTEM CANALIS LACRIMARIS
LAIN-LAIN
DIAGNOSIS PENUNJANG
1. Laboratorium
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2. Radiologi
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3. ECG
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4. Lain – lain
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DIAGNOSIS

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TERAPI

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Sragen, …………………………………………
Dokter Penanggung Jawab Perawatan
(DPJP)

( ………………………………. )
Tanda tangan dan nama terang
RM : 1m/Rev.1/2019 Asesmen Medis Rawat Inap Mata Hal. 2